Is Written Sign-Out Sufficient for Attending Hospitalists?
Abstract & Commentary
By Kenneth P. Steinberg, MD, FACP
Professor of Medicine, University of Washington School of Medicine, Seattle, WA
Dr. Steinberg reports no financial relationships in this field of study.
SYNOPSIS: Effective hand-offs and sign-outs are core competencies for hospitalists. This study suggests that attending hospitalists frequently use written sign-outs to address overnight inquiries but that the sign-outs are not reliably useful. Written-only sign-outs may not be sufficient for safe overnight care.
SOURCE: Fogerty RL, et al. Effectiveness of Written Hospitalist Sign-outs in Answering Overnight Inquiries. J Hosp Med 2013;8:609-614.
Hospital medicine is a rapidly growing specialty, and hospitalists can significantly impact the quality of care for hospitalized patients. One unique challenge of the hospitalist model is the shift-based care requiring transfers, or hand-offs, of care at shift change. Cross-coverage can be a high-risk aspect of care, and poor sign-outs can negatively impact cross-coverage, thus threatening patient safety. The Society of Hospital Medicine recognizes hand-offs and sign-outs as core competencies for hospitalists, but little is known about the quality of sign-out between hospitalists. For this reason, Fogerty and colleagues at Yale-New Haven Hospital attempted to assess how well hospitalist sign-outs prepared the night team for overnight events.
The study took place on the non-teaching Hospitalist Service at a large, urban, academic medical center (Yale-New Haven Hospital). A written sign-out built into the electronic health record is the major mechanism for shift-to-shift information transfer at that hospital. Verbal sign-out is reported to rarely occur on that service. The study took place on 6 non-consecutive days over a 6-week period of time. For every inquiry about a patient’s care received by the night hospitalist, that hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign-out, which information was used other than the written sign-out, and whether the inquiry was about an event that had been anticipated by the daytime team. Informed consent was obtained from all participating hospitalists. A composite quality score for the written sign-out was used. The score gave 1 point for each of the following elements: diagnosis or presenting symptoms, general hospital course, current clinical condition, and whether the sign-out had been updated within the last 24 hours. The composite score could range from 0 4. The primary outcome measure was the quality and utility of the written-only sign-out as defined via a subjective assessment of sufficiency by the covering physician. Specifically, the question was whether the written sign-out was adequate to answer the query without seeking additional information.
The night hospitalists recorded 124 inquiries during the study. Most (82%) were from nursing staff. None of the written sign-outs had a composite score of 0 or 1; 4% had a composite score of 2; 46% had a composite score of 3; and 50% had a composite score of 4. Seventy-two percent (72%) of the written sign-outs included neither anticipatory guidance nor tasks (a to-do list). Overall, the sign-out was considered sufficient to respond in only 30% of the inquiries, while 77% of the inquiries were considered to be clinically important by the hospitalist. Sign-out was considered to be sufficient to answer the majority of the order reconciliation inquiries but was less effective at helping to answer inquiries about clinical change, medications, and plan of care.
Most studies on the quality of hand-offs and sign-out have focused on trainees (residents and students). This study demonstrates that attending hospitalists also rely on sign-out, despite their higher level of training, as the written sign-out was used to help respond to three-quarters of the overnight inquiries. However, the written sign-out was felt to be sufficient to answer less than one-third of the inquiries in which it was referenced. Most notable, perhaps, was the suggestion that sign-outs were more likely to be effective if they included more anticipatory guidance for possible events.
Quite honestly, this is not a particularly strong study. It is a single-center study with a small sample size over a short period of time. The composite quality score is not well validated, making its use suspect, and patient outcomes were not evaluated. However, it is one of the first to look at the quality of attending-level hospitalist sign-out. Due to the structure of the service at Yale-New Haven Hospital, the study is also able to focus primarily on the sufficiency of written sign-out. The investigators made the observation that written-only sign-out was insufficient to deal with the majority of the cross-coverage inquiries. Most experts recommend that there be both written and verbal components to handoff communication, and this study appears to support the contention that written-only handoffs are insufficient. Perhaps, as noted by the authors, the written sign-outs could be improved by including more anticipatory guidance (e.g., "if... then..." statements). Anecdotally, I am a believer in the value of a supplemental verbal sign-out. Nonetheless, I agree with the authors’ conclusion that more work is necessary to better understand the benefit of improving written sign-out as well as the additional impact of verbal sign-out on overnight patient safety.